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The Real Gorilla in the Reading Room


Politicos with an agenda will wave the gorilla article and say radiologists need more oversight to ensure we don’t miss gorillas while they’re still treatable.

By now, you’ve probably heard about how some radiologists, looking for pulmonary nodules on chest CT, remained on task rather than focusing on a superimposed tiny gorilla on some images. People being how they are, and the media generally feeding into this, headlines have ranged from the tone of “Hey, check out this interesting psychological quirk” to “Your radiologist is even more of an idiot than the last time we ran an article about him.”

Since some of the public reading such coverage - heck, let’s be honest and recognize that many just glance at the headline, guesstimate what the actual text of the article was about, and move on - are in positions of governmental and other regulatory authority, one might reasonably be concerned as to how they might act on this.

I’m not saying that I expect a new series of diagnostic codes for different kinds of primate that might be found in imaging studies, nor a set of Appropriateness Criteria on the workup of incidental simians, though I have to admit that recent antics on the national healthcare front are such that moves in this direction would not terribly surprise me.

What I could see happening, as second- and third-round coverage of this story proceeds, is an increasing focus on the potential of radiologists to miss incidental findings. Anybody actually reading studies knows that the bulk of our time is spent looking over stuff that’s more or less normal; if all I had to do on a “R/O appy” CT was to glance at the appendix and move on, for instance, I could churn through RVUs like nobody’s business.

In the real world, though, my search pattern covers everything that was imaged, and what really slows me down is reporting on all of the incidental stuff along the way - or confirming its absence. We’ve seen more than a couple of write-ups about the detection and management of incidental findings for this very reason.

All our time spent searching for this ancillary stuff - as well as doing CME and occasionally even original research about it - unfortunately won’t hold a candle to a politico with an agenda. They’ll wave around the gorilla article, and perhaps one or two follow-up studies, and make dire predictions about how we’re just as human as everyone else, needing more oversight to make sure we don’t slack off and miss subtle gorillas while they’re still treatable.

Unfortunately, these are the same non-radiologists (and non-physicians, for that matter) who have demonstrated both willingness and ability to meddle in every aspect of the work we do. Their machinations have resulted in a steady stream of cuts in reimbursement and an ever-increasing volume of administrative scut-work for us, such that we must churn through ever more cases in order to stay afloat, much less get ahead.

Thus far, we’ve tried to adjust by finding more efficient ways to get things done, cutting overhead (such as by letting staff go - great tonic for the economic “recovery”), adding hours to our work weeks, and the like. No business, medical or otherwise, has infinite reserve, however, and many of us are running out of options.

Yet, with the promise of “affordable care” for everyone and the increasing usage of mid-levels to compensate for the lack of primary-care physicians interested in continuing to play the losing healthcare-provider game, we can look forward to further increases in volume of work to be done, of course at even lower reimbursement than before. As we increasingly flail to keep up, I daresay we’ll be more likely to ignore little anthropoids lurking in the corners of our imaging-studies.
That, my friends, is the real gorilla in our reading-room.

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